Paul Greaves: Consultant Haematologist Barking, Havering & … · 2019. 3. 6. · Pearls:...
Transcript of Paul Greaves: Consultant Haematologist Barking, Havering & … · 2019. 3. 6. · Pearls:...
Haematology for Clinical Finals
Paul Greaves: Consultant HaematologistBarking, Havering & Redbridge Hospitals NHS Trust
21 Cases, Take Home Messages & A framework for cramming@bloodworkapp
Inherited blood disorders
Inherited diseases
Hb structural problems
Interpretation of FBC
interpreting iron studies
Myelodysplastic syndromes
Medications
malaria
Rare confusing blood disorders
Blood disorders
Blood borne diseases
Blood test interpretations
Bloods - sickle cell, polycythemia
DIC
Everything
data interpretation
Which topics did you want…? December 2018 survey...
The rest...
The whole of haematology in 60 minutes...In 21 cases, Take-home messages and a revision framework
Haematology: Organising your cramming...
1. Clotting2. Transfusion3. Cancer4. Red cell5. Dire emergencies you must never mess up
CLOTTING: 5 key topics
1. PT, APTT and two ways to make a clot2. How to use heparin, warfarin and NOACs3. What to do with a bleeding patient taking anticoags4. Bleeding tendency5. Clotting tendency
TRANSFUSION: 5 key topics
1. Red cells: ABO, Rh and K2. Plasma3. Platelets (and thrombocytopenia)4. Tranexamic Acid5. Cryo, Fibrinogen, Expensive extras
➢ octaplex, novoseven, factor concentrates
CANCER: 5 key topics1. Presentation
➢ lumps, organomegaly, bone marrow failure, infection
2. Diagnostics ➢ scans, bone marrow, biopsy, blood film, flow, cytogenetics
3. Treatment ➢ chemo, radio, targeted antibodies, targeted molecules
4. Supportive care➢ antiemetics, mouth-care, antimicrobials, bisphosphonates, psychosocial
5. Emergencies➢ sepsis, tumour lysis, leukostasis, cord compression
CANCER: 4 key diagnoses
1. Leukaemia2. Lymphoma3. Myeloma4. Myeloproliferative Disease
RED CELL: 4 key topics
1. Haematinics2. Haemoglobin/opathy3. Haemolysis4. Haemochromatosis
5 things to NEVER MESS UP
1. Massive Transfusion and transfusion reactions2. Sepsis, Tumour Lysis & Hypercalcemia3. Cord Compression4. Sickle Chest crisis5. Dangerous thrombocytopenias
Pearls: dangerous thrombocytopenias
● Patient well or unwell?● Check out the blood film!
● Neurology, renal, fevers, haemolysis, RC framents -> TTP● Pregnant, LFTs deranged, Proteinuria -> HELLP● Heparin, Rash, Thrombosis -> HITT● Pancytopenia, abnormal WC on film -> Acute leukaemia
Anaemia 101
● Check MCV● Check other blood counts● Check haematinics● Look at blood film
You’ll usually have the answer then...
There are 3 kinds of anaemia
Macrocytic Normocytic Microcytic (usually also hypochromic)
Pearls: Microcytic Anaemia
IRON DEFIENCY or THALASSEMIA: nothing else!Check FERRITIN - if it’s low they’re definitely deficientDon’t give iron if ferritin is normal
IDA is not a diagnosis but a symptom● DIET, MALABSORPTION or BLEEDING?● Bleeding is GYNAE or GUT: The history will tell you● No clear blood loss: Check for Ca Bowel or Bladder
Don’t Transfuse unless active bleed: ● Fe replacement will do it
NR
Hb 62 120 - 160 g/l
MCV 65 80 - 100 fl
MCH 17 26 - 33 pg/c
RDW 20 12 - 15%
WCC 11 4 - 10 x109/l
Nph 8 2 - 8 x109/l
LC 3 1 - 4 x 109/l
Plt 550 150 - 450 x 109/l
88, White British, FEMALE 28, Bangladeshi, FEMALE
NR
Hb 62 120 - 160 g/l
MCV 65 80 - 100 fl
MCH 17 26 - 33 pg/c
RDW 20 12 - 15%
WCC 11 4 - 10 x109/l
Nph 8 2 - 8 x109/l
LC 3 1 - 4 x 109/l
Plt 550 150 - 450 x 109/l
28, Black British (Ghanaian parents), MALE
NR
Hb 102 120 - 160 g/l
MCV 55 80 - 100 fl
MCH 23 26 - 33 pg/c
RDW 14 12 - 15%
WCC 11 4 - 10 x109/l
Nph 8 2 - 8 x109/l
LC 3 1 - 4 x 109/l
Plt 400 150 - 450 x 109/l
NR
Hb 102 120 - 160 g/l
MCV 70 80 - 100 fl
MCH 23 26 - 33 pg/c
RDW 19 12 - 15%
WCC 11 4 - 10 x109/l
Nph 8 2 - 8 x109/l
LC 3 1 - 4 x 109/l
Plt 400 150 - 450 x 109/l
58, White British, MALE
Pearls: ThalassemiaHbA = 2 alpha chains (4 genes) & 2 beta chains (2 genes)Alpha thal = alpha gene problems; Beta thal = vice versa!
Trait: some genes still working● Not pathological but need antenatal testing and counselling
Major: no genes working -> PROBLEMS● Ineffective erythropoiesis -> anaemia & developmental issues● Extramedullary erythropoiesis -> skeletal deformity● Rx: Chronic Transfusion & Chelation ● Iron overload and chronic anaemia -> endocrinopathy, cardiopathy● Cure with bone marrow transplant● Future cure with gene therapy
Pearls: Macrocytic AnaemiaAcute: HAEMOLYSIS / AIHA / Acute leukSubacute: FOLATE (esp pregnancy)Chronic: B12, thyroid, alcohol, MDSTests:● Reticulocytes (up in AIHA, down in others)● B12 & Folate = Dietary or Pernicious
○ Don’t transfuse without haematinics○ Overtransfusion of chronic anaemia
kills● DAT● Liver Function and Thyroid Function● Blood Film
88, FEMALE, Collapse, Jaundiced, Confused
Hb 42 120 - 160 g/l
MCV 130 80 - 100 fl
MCH 28 26 - 33 pg/c
RDW 25 12 - 15%
WCC 3 4 - 10 x109/l
Nph 1.8 2 - 8 x109/l
LC 1.2 1 - 4 x 109/l
Plt 55 150 - 450 x 109/l
ALP 100 40 - 120 IU/L
ALT 35 5-50 IU/L
BR 25 5 - 16 mcmol/L
LDH 2000 >450 IU/L
Hb 95 120 - 160 g/l
MCV 82 80 - 100 fl
MCH 33 26 - 33 pg/c
RDW 16 12 - 15%
WCC 8 4 - 10 x109/l
Nph 6 2 - 8 x109/l
LC 3 1 - 4 x 109/l
Plt 400 150 - 450 x 109/l
ALP 200 40 - 120 IU/L
ALT 52 5-50 IU/L
BR 30 5 - 16 mcmol/L
LDH 500 >450 IU/L
35, MALE, Jaundiced
Pearls: Haemolytic AnaemiaIf LDH & BR hi & Haptoglobins absent there IS haemolysis!
DAT positive?● YES… probably immune
● NO… consider○ Lab issue!○ Membrane (HS & HE)○ Enzymes (G6PD & PKD)
36, Nigerian, Male, Leg pain, Chest Pain
Known HbSS sickle cell disease
What are the priorities of management
What are your targets and guidelines?
What are the short-term complications and how to prevent them?
What are the long-term complications?
Hb 72 120 - 160 g/l
MCV 77 80 - 100 fl
MCH 23 26 - 33 pg/c
RDW 18 12 - 15%
WCC 22 4 - 10 x109/l
Nph 15 2 - 8 x109/l
LC 4 1 - 4 x 109/l
Plt 700 150 - 450 x 109/l
What are the haemoglobinopathies and how to diagnose them?
PEARLS: Sickle Cell Disease● Lifelong, life-limiting, multisystemic disease● Hb SS, Hb SC and Hb Beta Thal all sickle
● Treat with individualised care plans● All patients on FOLIC ACID and PENICILLIN-V
● OPIATE ANALGESIA, 20 mins, 1 hr pain targets● Bloods, Oxygen, Fluids (oral or IV), Spirometry● Possibly also… CXR, ANTIBIOTICS, TRANSFUSION●● LONG-TERM: Hydroxyurea, Transfuse, Chelation● CURE: Bone marrow Transplantation & Gene Rx
PEARLS: Sickle Cell CrisesPAIN: Limb or Axial including SKULL or CHEST
CHEST: Pain, Hypoxia, Pulmonary Infiltrates○ Oxygen, Analgesia, Antibiotics & Spirometry○ Ventilatory Support, Exchange Transfusion
APLASTIC: Parvovirus (or drug); TRANSFUSE
Sequestration: Liver (or spleen); TRANSFUSE
SEPTIC: Recognise Early, Treat, Re-assess
D E
B
CA: CMLB: AMLC: MMD: CLLE: CHL
A
Haem-onc: Name that cell…!
Baseline tests:● Biopsy - Lymph node, bone marrow
● FBC: Marrow failure often a complication (+ haematinics)● Chemistry: Tumor lysis, Calcium, Liver infiltration, Fitness
● HIV and Hepatitis status check● Autoimmune and thyroid
Supportive Care:○ Antimicrobials, BMFx, Analgesia, Mouthcare, Antiemetics,
Anti-TLSx
PEARLS: Haem Cancer WorkupDIAGNOSE -> STAGE -> PROGNOSTICATE -> SUPPORT
Staging determines TREATMENT and PROGNOSIS
Lymphomas: IMAGING: CT / PET CT
Myeloma: Skeletal survey, MRI spine
Leukaemia: MolecularImmunophenotyping defines cell typeCytogenetics determines prognosis
PEARLS: Haem Cancer Staging
Old Style; Still Work!● Cytotoxics: Damage DNA / Cell replication -> Apoptosis● Radiotherapy: Regionally targeted DNA damage -> Apoptosis
‘Novel’ Agents:○ Monoclonal antibody: target tumour; immune modulate or
carry cytotoxic or radioactive substance■ E.g. Rituximab, Daratumomab
○ Oncogenic pathway blocker - ‘small molecule inhibitor’■ E.g. Imatinib, Ibrutinib
○ Esoteric mechanism not fully understood!■ E.g. Lenalidomide, Bortezomib
PEARLS: Haem Cancer Treatment
24, Female: Cough, swollen glands, Fevers, FatigueHb 110 120 - 160 g/l
MCV 92 80 - 100 fl
MCH 28 26 - 33 pg/c
RDW 14 12 - 15%
WCC 13 4 - 10 x109/l
Nph 11 2 - 8 x109/l
LC 2 1 - 4 x 109/l
Plt 500 150 - 450 x 109/l
ALP 165 40 - 120 IU/L
ALT 250 5-50 IU/L
BR 15 5 - 16 mcmol/L
Non-Hodgkin: 5th commonest cancerUSUALLY B CELL, High Grade or Low Grade
High Grade = DLBCLLow Grade = Follicular lymphoma
T cell rare (10%) = Immune disruption++
Other exam-topic B cell lymphomasBURKITT: rare super-highgradeKey facts: EBV, C-MYC, t(8;14)Key types: SPORADIC, ENDEMIC, IMMUNOSUPPWALDENSTROM: Lo grade +IgM paraprotein AKA LPC lymphoma
Targeted Ab: RITUXIMAB (CD20) for B cell
Lymphoma 101 Hodgkin: Rare cancer but...2nd commonest teens /twenties Key facts:Reed Sternberg cells; 30% EBV+4 Histological subtypes: NS/MC/LP/LDTargeted Ab: Brentuximab (CD30)
Stage and treated both ‘the same’● Biopsy, CT or PET-CT: Anne
Arbor stage● Chemotherapy mainstay● Radiotherapy for localised● BM Transplant for relapse
28, MALE: ‘Flu’, Fatigue, Bone pain, and sore gums
Hb 65 120 - 160 g/l
MCV 112 80 - 100 fl
MCH 28 26 - 33 pg/c
RDW 18 12 - 15%
WCC 3 4 - 10 x109/l
Nph 0.9 2 - 8 x109/l
LC 1.5 1 - 4 x 109/l
Plt 40 150 - 450 x 109/l
ALP 165 40 - 120 IU/L
ALT 250 5-50 IU/L
BR 15 5 - 16 mcmol/L
Acute Leukaemia Pearls
The acute leukaemia are VERY SIMILAR in presentation & treatmentThe chronic leukaemias are COMPLETE DIFFERENT from each other!
Acute leukaemia: AML and ALLPresentation: Bone marrow failure, infections/bleeding, leucostasis Treatment: Chemotherapy +/- transplant; and CNS prophylaxisCytogenetics are prognostically essential:
t(15;17) GOOD, monosomy 3,5,7 BAD (AML)
LIFE THREATENING PRESENTATIONS!:Leucostasis, Tumor Lysis, Coagulopathy, Sepsis
84, Female: Fatigue, Abdominal discomfort
Hb 100 120 - 160 g/l
MCV 92 80 - 100 fl
MCH 28 26 - 33 pg/c
RDW 14 12 - 15%
WCC 48 4 - 10 x109/l
Nph 5 2 - 8 x109/l
LC 42 1 - 4 x 109/l
Plt 110 150 - 450 x 109/l
Cr 55 40 - 120 IU/L
Ca 2.3 2.2-2.6 mM Hb 110 120 - 160 g/l
MCV 92 80 - 100 fl
MCH 28 26 - 33 pg/c
RDW 14 12 - 15%
WCC 16 4 - 10 x109/l
Nph 5 2 - 8 x109/l
LC 8 1 - 4 x 109/l
Plt 140 150 - 450 x 109/l
18 months ago..?
54, Male: Fatigue, Abdominal discomfort
Hb 100 120 - 160 g/l
MCV 92 80 - 100 fl
MCH 28 26 - 33 pg/c
RDW 14 12 - 15%
WCC 48 4 - 10 x109/l
Nph 42 2 - 8 x109/l
LC 2 1 - 4 x 109/l
Plt 710 150 - 450 x 109/l
Cr 55 40 - 120 IU/L
Ca 2.3 2.2-2.6 mM Hb 110 120 - 160 g/l
MCV 92 80 - 100 fl
MCH 28 26 - 33 pg/c
RDW 14 12 - 15%
WCC 16 4 - 10 x109/l
Nph 12 2 - 8 x109/l
LC 3 1 - 4 x 109/l
Plt 140 150 - 450 x 109/l
18 months ago..?
Chronic Leukaemia PearlsChronic Myeloid Leukaemia is VERY RAREPresents with hepatosplenomegaly and very high white cell count● BCR-ABL is the gene driving it● t(9;22) is the cytogenetic lesion● Chemo / bone marrow transplant used to be needed● Now it’s just TARGETED therapy with IMATINIB or similar● Occasionally transforms into acute leukaemia (AML AND ALL!)
Chronic Lymphocytic leukaemia is COMMONEST LEUKAEMIAPresents incidentally with inc WCC; usually with palpable nodes● Behaves just like B cell non-Hodgkin lymphoma● Treated like B cell non-Hodgkin lymphoma● Occasionally transforms into high grade lymphoma (Richters)
Myeloproliferative Disease 101Three related disorders: PCV, ET & MF
○ ALL of PCV and ⅓ of others = mutated JAK2○ Most of ET/MF are JAK2 or CALR/MPL mutated○ MF = characterised by B symptoms & big spleen
Always excluded ‘secondary’ causes○ Erythrocytosis = HYPOXIA, EPO secretion or rare OXYGEN
AFFINITY / HYPOSENSITIVITY disorders○ Thrombocytosis = ACUTE PHASE or IDA
Complications: Thrombosis and transformation to AML/MF● Treat with ASPIRIN and CYTOREDUCTION (HU)
54, Male: Fatigue, Pruritis, Abdominal discomfort
Hb 190 120 - 160 g/l
MCV 105 80 - 100 fl
MCH 28 26 - 33 pg/c
RDW 14 12 - 15%
WCC 15 4 - 10 x109/l
Nph 13 2 - 8 x109/l
LC 2 1 - 4 x 109/l
Plt 710 150 - 450 x 109/l
Hct 62 40 - 50%
Diagnostic Test?
Anything else to exclude?
‘Adjunct’ tests
Treatment?
Complications?
Aplastic Anaemia:● Disease of mid-age● Sometimes curable● Autoimmune mechanism● Does not evolve to AML
Treatment:● Immunosuppression (ATG/CSA)
+ BMT
PEARLS: Bone Marrow Failure SyndromesEXCLUDE CONGENITAL and secondary causes: Nutritional/Viral/Toxin/Radiation
Myelodysplastic syndrome:● Generally incurable ● Disease of elderly● Neoplastic mechanism● Frequently evolves to AML
Treatment:● Growth factors● Hypomethylators & Lenalidomide● Chemo / BMT● Immunosuppression
Support with blood products and antimicrobial prophylaxis
64, Male: Back pain, Fatigue, PolydipsiaCr 200 40 - 120 IU/L
Ca 3.1 2.2-2.6 mM
Hb 100 120 - 160 g/l
MCV 92 80 - 100 fl
MCH 28 26 - 33 pg/c
RDW 14 12 - 15%
WCC 6 4 - 10 x109/l
Nph 5 2 - 8 x109/l
LC 1.5 1 - 4 x 109/l
Plt 140 150 - 450 x 109/l
PEARLS: MYELOMAMULTISYSTEMIC MALIGNANCY: CRAB criteria● Calcium, Renal, Anaemia, Bone● Infection, Thrombus, Amyloid
SUSPECT: Anaemia, bone pain, globulins, Hypercalcemia
TREAT DISEASE:● Chemo/RT● Novel agents: velcade & imids, targeted antibodies● Auto BMT
TREAT COMPLICATIONS:● Analgesia, Bisphosphonates, Anticoags, Antibios
BEWARE!: ● Cord Compression, Pathological #, Renal Failure, Infection
58, White British, MALE, TATTPMHx
Diabetes
Osteoarthritis
Hypothyroidism
20-30u beer/week
O/E
Tanned
Hb 122 120 - 160 g/l
MCV 102 80 - 100 fl
MCH 28 26 - 33 pg/c
RDW 14 12 - 15%
WCC 9 4 - 10 x109/l
Nph 6 2 - 8 x109/l
LC 3 1 - 4 x 109/l
Plt 400 150 - 450 x 109/l
ALP 165 40 - 120 IU/L
ALT 250 5-50 IU/L
BR 15 5 - 16 mcmol/L
Ferritin 6250 20 - 300 mcg/L
Transferrin Sat
58 <55%
HFEC282YH63D
PEARLS: Iron Overload
Hyperferritinemia =● ACUTE PHASE, LIVER … or iron overload
Iron Overload = ● Transfusional, Ineffective Erythropoiesis or H.H.
Complications: ● Liver, Endocrine, Cardiac, Joint, Skin● Hereditary (HH): Usually HFE gene C282Y or H63D
Treatment: ● VENESECT if H.H.● Iron Chelation if Ineffective Epoiesis/Transfusion
1. Malignancy2. Chronic Haemolysis3. Storage Disease4. Portal hypertension5. Systemic disease:
Infection / Connective tissue
Splenomegaly : CausesStorage DiseasePortal hypertensionLysis (haemolysis)ESR (connective tissue)Exotic (malaria/leishman/schisto)Neoplastic (Lymphoma, MPD)
PEARLS: Thromobosis
● CONGENITAL: FVL, PTM, ATD, PCD, PSD● ACQUIRED: Malignancy, TRAUMA, APLS, MPD● Major: HOSPITALISATION, HORMONE (pregnancy)● Secondary: Immobility, Smoking, Obesity
Indications for anticoagulation:● Prophylaxis of above● Prophylaxis in AF and Valvular disease
○ CHADS2Vasc and HASBLED srisk stratify AF● Treatment of VTE
○ Diagnose with IMAGING after WELLS SCORE○ Lifelong or 12/52 anticoagulation○ Depends on PROVOKED or UNPROVOKED
Clotting cascade…
Any volunteers…?
Pearls: Oral AnticoagulationWarfarin still has its place:
● Reversible, well tolerated, useful with renal impairment● ALWAYS for valvular heart disease (especially
prosthetics) and antiphospholipid syndrome● Takes 3+ days to work ● REVERSIBLE (Vitamin K and PCC)
Novel agents preferable for compliance & risk:● Rivaroxaban/apixiban/edoxaban: check renal function● Dabigatran sometimes (but GI bleeds and MIs?)● Partial reversal with PCC; targeted ‘antidotes’ available
Take Home: Parenteral AnticoagulationUnfractionated heparin rarely used
● Except CARDIOLOGY and RENAL IMPAIRMENT● APTT monitoring required: unpredictable pharmacokinetics● Risk of Heparin-induced Thrombocytopenia● Reversed with PROTAMINE (but has short half-life anyway)
LMWH (‘ultra-low’ Fondaparinux for ACS)● Many brands, pretty much the same
○ (dalte/enoxa/tinzaparin)● Predictable RENAL excretion: easy weight-based dosing ● Unlike UFH - IRREVERSIBLE (mainly)
○ 10-20 hour half-life
38 Female, Fatigue, Easy bruising limbs, ankle rash
What could be causing this?
Which investigations?
Confirmatory tests?
Hb 122 120 - 160 g/l
MCV 92 80 - 100 fl
MCH 28 26 - 33 pg/c
RDW 14 12 - 15%
WCC 9 4 - 10 x109/l
Nph 6 2 - 8 x109/l
LC 3 1 - 4 x 109/l
Plt 26 150 - 450 x 109/l
APTT 26 20 - 30 sec
PT 11 9 - 12 sec
Fib 2.3 1.5 - 4g/l
Hb 80 120 - 160 g/l
MCV 101 80 - 100 fl
MCH 28 26 - 33 pg/c
RDW 17 12 - 15%
WCC 9 4 - 10 x109/l
Nph 6 2 - 8 x109/l
LC 3 1 - 4 x 109/l
Plt 36 150 - 450 x 109/l
APTT 26 20 - 30 sec
PT 11 9 - 12 sec
Fib 2.3 1.5 - 4g/l
ALP 100 40 - 120 IU/L
ALT 35 5-50 IU/L
BR 70 5 - 16 mcmol/L
LDH 2000 >450 IU/L
Cr 700 40 - 120 IU/L
Ur 36.3 2.5 - 8 mM
38 Female, Fatigue, Easy bruising limbs, ankle rash, headache, fever
88, Male, Nursing home resident, Purpura, Abdo painHb 80 120 - 160 g/l
MCV 65 80 - 100 fl
MCH 28 26 - 33 pg/c
RDW 17 12 - 15%
WCC 9 4 - 10 x109/l
Nph 6 2 - 8 x109/l
LC 3 1 - 4 x 109/l
Plt 480 150 - 450 x 109/l
APTT >120 20 - 30 sec
PT 11 9 - 12 sec
Fib 2.3 1.5 - 4g/l
ALP 100 40 - 120 IU/L
ALT 35 5-50 IU/L
BR 20 5 - 16 mcmol/L
Cr 150 40 - 120 IU/L
Ur 13.2 2.5 - 8 mM
Neonate, Male, Post ventouse delivery, Unresponsive, Cefalhaematoma
Hb 120 160 - 180 g/l
MCV 105 100 - 110 fl
MCH 28 26 - 33 pg/c
RDW 17 15 - 20%
WCC 23 10 - 35 x109/l
Nph 18 5 - 21 x109/l
LC 8 2 - 10 x 109/l
Plt 380 150 - 350 x 109/l
APTT >120 20 - 30 sec
PT 11 9 - 12 sec
Fib 2.3 1.5 - 4g/l
What could be causing this?
Which investigations?
Confirmatory tests?
‘Late’ Complications?
Platelets abnormal: ● Mucocutaneous bleeds: Bruises
and purpura
Clotting proteins abnormal: ● Congenital haemophilia:
○ Joint bleeds● Acquired haemophilia:
○ EVERYWHERE bleeds○ muscle, retroperitoneal, GI,
mucosal, cranial
APTT abnormal?● It’s heparin, Lupus or HAEMOPHILIA
PT abnormal?● It’s warfarin, nutrition, liver or a RARE
haemophilia
BOTH abnormal?● It’s DIC, Liver or big anticoagulant
doses… check fibrinogen / FDPs - how’s the patient?
BLEEDING HISTORY better than labs
Pearls: Bleeding and Bruising
Red Blood Cells:For emergencies & congenital anaemias: Avoid if you canTranexamic acid in major bleeds
Patient Blood management: ● Conservative vs Liberal Hb ● Why use 2 when 1 will do?● Optimise iron (IV) +/- Epo● Fewer blood tests for patients● Salvage blood intraop● Treat anaemia cause before Hb
too low
Platelets:A scarce resource: emergencies only● Seek cause of new
thrombocytopenia● patient, drug chart & blood film
Excess use -> refractoriness● 1 unit usually adequate● Most invasive procedures
require platelets >30-50; only neurosurgery >100
● Remember to replace during massive transfusion
Take Home: Proper Transfusion
Plasma (FFP): Corrects deficiencies of all clotting factors (inefficiently)
No good for warfarin reversal
Use in massive transfusion (>6 units) NOT for DIC!
Cryoprecipitate:Fibrinogen concentrateGood for dys/hypofibrinogenemiaOccasionally DIC and obstetric bleeds
Prothrombin Complex Concentrates:LIFE THREATENING warfarin bleedsPartially reverse the DOACs
Clotting factorsOnce were ‘super-concentrates’Now RECOMBINANTS (no viral risk)● Factors VIIa, VIII, IX and VWF● Generally for HAEMOPHILIA
FEIBA = Activated PCC● For haemophilia with inhibitors
Novo7 = occasionally in trauma
Take Home: Blood Products
That was…Haematology for Clinical Finals
Paul Greaves: Consultant Haematologist, BHRUT, Romford
...any questions? (now or later: [email protected])
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